HomeMy WebLinkAbout0108 MEGAN ROAD - Health N
108 MEGAN ROAD, HYANNIS
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�,�hbIL11 C ASSESSOR'S MAP & LOT2
STALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 0
LEACHING FACIL.rIY: (type) 1 1 �.'TIf�Qu - (size) A(.AC. I.
+ 1
NO.OF BEDROOMS
BUMDEI?OR OWNER,��U�T10S-\i�
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom ofLeaching Facility . Ft"
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)
E4ge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Fe=
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r, EXECUTIVE OFFICE OF EN-VIRONMENTAL AF : ►R�JU
DEPARTMENT OF ENVIRONMENTAL PROTE f N Q 1999
ONE WINTER STREET. BOSTON M-k 0210E (617) 292-5.5oo �R
COS
% ecre:ar,
ARGEO PALL CELLUCCI DAVID B. STP.Cominiss e::.-. r
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
`' 9 �� CERTIFICATION
UT
Proper �S �- �� Name of Owner
ty Address: SCJZ.�� {.�
Address of Owner: le tq
Date of Inspection:. l 5 ,�+C�/ // V�1�5� `Y J A. , C32lo�
Name of Inspector:(Please p)fft)/ ( •C- a f r)EC K U i
e 5(310 CMR 15.0001
1 am a DEP approved system inspector pursuant to Section 15.340 of Tru
Company Name: A7Yu�1,r
Mailing Address: ., 4
Telephone Number: 4�
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_-- Fails
Inspector's Sigmtzke: r Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer•if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 PAgeiortl
t: Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
_ PART A
t• ) CERTIFICATION (continued)
'roperty Address: ,U� —1O-V�/
Jwner: " .,T
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY,PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes,.no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
_ The septic tank is metal• unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipelsi
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
Inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2 of 11
I `
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determ' a if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE H 310 CMR 15.303(1)(b) THAT_THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH D SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a aft marsh.
21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC ATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEAL AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption system SAS) and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption syst and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption sys m and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption sy tem and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water anal sis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and t presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distanc (approximation not valid).
3) OTHER
revised 9/2/98 Page 3ofIt
SUBSURFACE
SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property
Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as de cribed in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to d termine what will be necessary to correct the failure.
Yes No
_ Backup of sewage into facility or system component due to an ove oaded or clogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or rface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert d to an overloaded or clogged SAS or cesspool.
Liquid Pi uid depth in cesspool is less than 6" below invert or ava'able volume is less than 1l2 day flow.
_ Required pumping more than 4 times in the last year NO due to clogged or obstructed pipe(s).
Number of times pumped_.
_ Any portion of the Soil Absorption System, cesspool r privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 f t of a surface water supply or tributary to a surface water supply.
_ Any portion of a cesspool or privy is within a Z e I of a public well.
_ Any portion of a cesspool or privy is within 5 feet of a private water supply well.
Any portion of a cesspool or privy is less t an 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the ell has been analyzed to be acceptable, attach copy of well water analysis for
•coliform bacteria, volatile organic comp nds;ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large system in addition to the criteria above:
9 Y
The system serves a facility with a desig flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment b cause one or more of the following conditions exist:
Yes No
the system is within 400 f et of a surface drinking water supply
the system is within 20 feet of a tributary to a surface drinking water supply
the system is located a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone (I of a public
water supply well)
The owner or operator of any such sy em shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further i ormation.
revised 9/2/98 Page4of11
s �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Lv�, -qw'^
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and-the system has been receiving rwrmal flow
rates- during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N.A.
The facility or dwelling was inspected for signs of sewage back-up.
K _ The system does not receive non-sanitary or industrial waste flow.
)( — The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge. depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
KExisting information. For example. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
115.302(3)(b)I
XThe facility owner (and occupants,if different from owner) were provided with information on the propermaintesanra-0f
SubSurface Disposal Systems.
revised 9/2/98 Paecsorllt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'roperty Address: tiN&"0.,Vj
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:��a g•p.d.lbedroom.
Number of bedrooms (design): Number of bedrooms (actual)
Total DESIGN flow d
Number of current residents:
Garbage grinder(yes or no):_
Laundry (separate system) ( s orr It yes, separate inspection required
Laundry system inspected es no)
Seasonal use (yes or no): /,—,C7
Water meter readings, if available (last two year's usage (gpd).
Sump Pump(yes or no): :* j0
Last date of occupancy:�L-V-5
COMM ERCIALANDUSTRIAL:
Type of establishment:
Design flow: qpd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes ir�no)�—(,s
If yes, volume pumped: gallons
Reason for pumping:
TY OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous Inspection records.if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date Installed(if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)+A-A::,
revised 9/2/98 ' Page 6of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address: � U-qc{ct(oi
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction: _cast iron_40 PVC_ other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_,
(locate on site plan)
Depth below grade: ` 5
Material of construction: concrete_metal_Fiberglass _Polyethylene _other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions:
Sludge depth: CAn 9
Distance from top of sludge to bottom of outlet tee or baffle:
-36
c:
Scum thickness:_ , tt
Distance from top of scum to top of outlet tee or baffle:—
Distance from bottom of scum to bottom of outlet tee or baffle:_
How dimensions were determined:
lomments:
pumping, condition of inlet and outlet tees or baffles, depth liquid level in relation to outlet in rt, structural integrity.
(recommendation for
evidence of akage,etc.) ��a..l
O�
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass ,_Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
tion of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity.
(recommendation for pumping, condi
evidence of leakage,etc.)
revised 9/2/98 Psge7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
_metal_Fiberglass _Polyethylene_other(explain)
Material of construction: _concrete
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes _ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:-bJ1'fl
(locate on site plan)
Depth of liquid level above outlet invert:
Comments: -
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,•condition of pumps and appurtenances,etc.)
revised 9/2/98 page aoril
i -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (conbrwed)
-YSTEM (SAS):
possible; excav tion not required, location may be approximated by non-intrusive methods)
number: �leX(,o
ambers, number:_
feries, number:_
aches, number, length: t Sy rtQ�X,
As, number, dimensions:
sspool, number._
system:
:me of Technology:
signs of hydraulic failure, level of ponding, damp soil, c ditio of vegetation, etc.)
>ftw� So, lr
-Lion:
inlet invert:
.ol•
:lion:
rater:
spool must be pumped as part of inspection)
signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
r
;on.. Dimensions:
s'. signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r
PART C
SYSTEM INFORMATION (continued)
OSAL SYSTEM:
'east two permanent reference landmarks or ben a,ko house)
thin 100' (Locate where public water supply comes
inttiD-6
101,
63�3�
?/98 page 10or11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
roperty Address:
Owner:
Date of Inspection:
NRCS Report name ('"� - --- ---- ---
Soil Type_ — -------- ----
Typical depth to groundwater—___._ __
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep—_
SITE EXAM Slope (F-0
Surface waterpJC
Check Cellar
Shallow wells &6 i
42(
Estimated Depth to Groundwater y Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property. observation hole. basement sump etc.)
Determined from local conditions
}
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators. installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
revised 9/2/98 Page 11 of 11
TROY WILLIAMS
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508) 760-1819
40 Old Bass River Road
South Dennis,MA 02660
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property / d 8 m e `/u N WCA /- y G•„,,,; s
Owner's name& 41 6e, f- c,,,, /vl e-e-y f' CCX,—CA LoJfl
Mailing address ` (i o�, c- s `✓, /44
Date of Inspection
PART A
CHECKLIST �
Check if the following have been done:
9
Pumping information was requested of the owner, occupant and Board ofiHealth.
None of the system components have been pumped for at least two weeks and the
system has been receiving normal flow rates during that period. Large volumes of
water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with
N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
_/All system components, excluding the SAS, have been located on the site.
LThe septic tank manholes were uncovered, opened, and the interior of the septic
tank was inspected for condition of baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge, depth of scum.
1/ The size and location of the SAS on the site has been determined based on existing
information or approximated by non-intrusive methods.
The facility owner(and occupants, if different from owner) were provided with
information on the proper maintenance of SSDS.
Page 1 of 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
_L number of bedrooms
— number of current residents
IV 6 garbage grinder, yes or no
-yg-5 laundry connected to system, yes or no
seasonal use,yes or no
If nonresidential, calculated flow:
Water meter readings, if available: 9
oJ
e J Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
�a c tiJ ^' 'J-e-a yl27/551 .2 _- /-c e.�J s c� 3'
777�-
/V o System pumped as part of inspection,yes or no
If yes,volume pumped
Reason for pumping:
Type of system
t� Septic tank/dissr-ibution be%/sod absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (If yes, attach previous inspection records, if any)
Other(explain)
Amp-proximate age of all components. Date installed, if known. Source of information:
U N'Lt A p o4 t� i-�- A✓ t y r t ', 4- I )'D 43 D ~-L 'i.�i V- A ✓6X
b6f&j. d. ,- CL41oIId iti 'y'� ntr us lu i /�
N° Sewage odors detected when arriving at the site, yes or no
Page 2 of 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: %/ (locate on site plan)
depth below grade:
material of construction: concrete metal FRP other(explain)
dimensions: S X 9 ?l 6 ' /o o o y /A, „ .
3,, sludge depth
�Z// distance from top of sludge to bottom of outlet tee or baffle
scum thickness
distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation
to outlet invert,structural
structueral integrity,evidence of leakage,re/commendations for repairs,etc.)
d/ cc GN L✓4 'el .d —.A
DISTRIBUTION BOX: 6✓e/ (locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,
recommendation for repairs,etc)
PUMP CHAMBER: (locate on site plan)
pumps in working order,yes or no
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, recommendations for
maintenance or repairs,etc.)
Page 3 of 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOEL ABSORPTION SYSTEM(SAS):
(locate on site plan,if poss.;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of
ve etation,recommendations for maintenance or repairs,etc.)
CESSPOOLS (locate on site plan) : N114
number and configuration
depth-top of liquid to inlet invert
depth of solids layer
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater inflow
(cesspool must be pumped as part of inspection)
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of
vegetation,recommendations for maintenance or repairs,etc.)
PRIVY: /k//� (locate on site plan)
materials of construction
dimensions
depth of solids
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of
vegetation, recommendations for maintenance or repairs,etc.)
Page 4 of 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
31
DEPTH TO GROUNDWA
depth to groundwater — adjusted high groundwater level
method of determination or approximation:
11 S G A G✓o PU 6-0 f s
W r _
Page 5 of 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no or not determined(Y,N, or ND). Describe basis of determination in all
instances. If"not determined", explain why not)
Backup of sewage into facility?
N Discharge or ponding of effluent to the surface of the ground or surface waters?
,64&Static liquid level in the distribution box above outlet invert?
A1119 Liquid depth in cesspool<6"below invert or available volume< 1/2 day flow?
Required pumping 4 times or more in the last year?
Number of times pumped
Septic tank is metal? cracked?structurally unsound? substantial infiltration?
substantial exfiltration?tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
_AL within 100 feet of a surface water supply or tributary to a surface water supply?
within a Zone I of a public well?
/V within 50 feet of a bordering vegetated wetland or salt marsh(cesspools and privies
only, not the SAS)?
�-� within 50 feet of a private water supply well?
less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis? If the well has been analyzed to be acceptable,
attach copy of well water analysis for coliform bacteria, volatile organic
compounds, ammonia nitrogen and nitrate nitrogen.
Page 6 of 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector: Troy Williams
Company Name: TROY WILLIAMS SEPTIC INSPECTIONS
Company Address: 40 Old Bass River Road, South Dennis, MA 02660
Certification Statement
I certify that I have personally inspected the sewage disposal system at this address and
that the information reported is true, accurate and complete as of the time of inspection.
the inspection was performed and any recommendations regarding upgrade, maintenance
and repair are consistent with my training and experience in the proper function and
maintenance of on-site sewage disposal systems.
Check one:
—A—/I have not found any information which indicates that the system fails to adequately
protect public health or the environment as defined in 310 CMR 15.303. Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and the environment
as defined in 310 CMR 15.303. The basis for this determination is provided in the
FAILURE CRITERIA section of this form.
Inspector's Signature ,S
Date 2$�42 /
Original to system owner
Copies to :
Buyer(if applicable)
Approving authority
PROPERTY ADDRESS:
/o 9 Al --e L , a;U .
uv► rX S
Page 7 0 7
_ TOWN OF BARNSTABLE
LOCK-,!ON SEWAGE#
VY'.,.LAGE- ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. Al
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 02 �� (size)
NO.OF BEDROOMS
BUILDER OR OWN../ER
PERMIT DATE:_IT�dZ r g�� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of lea_ching,facility) Feet
Furnished by�— l u 0'4
t
__
1
-C.
^ ^ 6\
V�
` ` �'
�h^' --L ,
W �� � r
1 �
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W
� vRr
� ��� �,
.� . ��
� _
TOWN OF BARNSTABLE
LOCATION �/ �''' r�a� SEWAGE --/T9
r,
VILLAGE ASSESSOR'S MAP & LOT
J. CRAIG MEDEIROS Soy
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY [ 1VNIS' MA 02601
LEACHING FACILITY:(type) " '�k(size) /a a s 97/ ,9't
NO. OF BEDROOMS PRIVATE WELL OR(!�URLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: �1�/'��7
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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PARCEL NO:—Z V 6
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
c TOWN OF BARNSTABLE
I�
Appliratilan for Uh4p ti al Workii Tomitrurtiun ramit
9—t'Pipplication is hereby made for a Permit to Construct ( ) or Repair (L an Individual Sewage Disposal
System at: 0 r10 e_q 1D2 A/ Ra E4
................_. -_.........---••--• ----•••-•-••••-•-••-...._•---•---------- --.......•--•_... . ---------------------------
..........
� - a ion-Address o t No
,,ss E ?' �..►fr..w�J 8 !`• tee ' ,
O ner (� A dress
�w rout
Installer Address
Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
-------------- No. persons---------------------------- Showers —
a Other—Type of Building ______________ p � ( ) Cafeteria ( )
Otherfixtures ------------------------•-----=--•--------------•---.....---------------...-----------------------•------------•---•----------.....•-•---------------.
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity........_...gallons Length................ Width................ Diameter.-.------.-.-_- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No----_-------------- Diameter.............--.---. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water----....................
44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water....................--..
R+ --------•---------------------------........................................................................................................................
Descriptionof Soil _ •--------------------------•------------------------------------------------------------------•---------•---------------
---------------------------------------------------------
x ...............----•--------------------•-------------------------------•--------•---•--•-••-••--------•--------•-----------•--•------•------- ---
U Natu of Repairs o Alterations—Answer when licable...... ^n--�' �.j ..... :�.✓_ _
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia ce has been issued by the board of health.
Signed...-..
- Date
ApplicationApproved By .......... :A'"......... ... ....... -- ....'--------------------------------------------------------. ----------------------------------------
Date
Application Disapproved for the following reasons' ...................................----------------..................................................................................
-----------------------------------------------------------------------------------------------------------------------------..........................................................---------------------- -- -------------------------------
Date
Permit No. .... -- _ ,—z
-- ------- ------------- Issued ..........
--------Date............ .'----- -...---------
C27
No..l..` `''_ '! U Fes$...... ....
THE COMMONWEALTH OF MASSACHUSETTS-
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diapas al Marks Tnnitrnrtinn ami#
Application is hereby made for a Permit to Construct ( ) or Repair (L��n Individual Sewage Disposal
System at:
t ........... .......................... ...........1...---/�a
v
Location-Address / �& or`Lot No.
' °` e" � .`d,/_ fFvTlG'� 1....................................................
Owner Address
........... ...... ..-:-........------.......-.........:..._,..,..----........--..........
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—T
ype of Buildin g _______.•_____________..... No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures --•--------------------------------------------........................................
Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity............gallons Length.........------ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by................................ .......................................... Date-----------........................................
Test Pit No. I................minutes per inch Depth of Test Pit............._...... Depth to ground water........................
r1r4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--••----• •-•--•------•-----••-••-----•••------•---•••---•••-•••-•----•-•...-•--------•.._......---•..............•-------•--•---•-••-•--•-----•-----•.-----
x . Description of Soil--_---•-___--_ 1_�
�z • ti
U -----•---------•-•--•-••••--•--••------•••......------•-•-------•-•-•--•••------------•--••-••---....•---••-•-•-----••-•--•••--•--•--•-•••--••-•-•----••-•------------••.................••---------••-
UW -•-•.......................................•----•-------------------•---•-••--•---------•---•-•••-••---••--•--•...........-----•-----•-------
Nature of Repairs,or Alterations—Answer when applicable.-._.. _ _ '�_�_+�_ /_. __•-/_u- ✓- . =. (7..?' 2.
- - -.
�'�v `*.f'.,/(/`� C..fi.. C../ --•'`sf'.'�r L_./ 6"•__--." ,.� .'0 :GEs+"r___..' ;r L.n,/, ,--,�-1 ,
Agreement: -�^�) `
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued�by the/board of health. '
Signed r -..�_..- --; `° \�'t✓�.c�..--- �!/�
I .
} Dace
Application Approved By ------...............#--*V------�f.. - - ........ ........... --- -..------ -----------
- .. ...Dare
Application Disapproved for the following reasons: .------.. .. ...... .. ................. ............ _........... __..
------------------------------------------------------------------------------------- -------------------- -....-------------------------------------------- ----------------------------------------
(� / + Dare
Permit No. ....f.. `"-_/-..f9- Issued .......r�^ '�.....�9
f Daze
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Ierttf rate of (1:umpliance
THIS IS TO CERTIFY, Th t the Indi�v duarSewage Disposal System constructed ( ) or Repaired ( )
Y -------, - - -
Insea#ICr�a
.............
has been installed in accordance with the provisions of TITLE 5,ofQ The State Environmental Code as described in
the application for Disposal Works Construction Permit No.�F_ - .. dated _41(��._ ...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFAC11O.RY.
DATE -- - �.. / I."..,----- . .......... `/. -`.-- -------- Inspect r" f
�------- —- -�.......-.....------------------------ THE COMMONWEALTH OF MASSACHUSETTS ! / -
BOARD OF HEALTH
TOWN OF BARNSTABLE FEE. -�_-Y........
...........•-----
Disposal Morb Tomitrnrfion Trani#
Permission is hereby granted... --•-��":". ?_1 ! ..a'. ?_
- ----------••----------------------------•••-----.--.--------------------=---
to Construct ( ) or Repair („_) an�Ind virlual Sews ge Disposal System 1
at No.r r.....................................`. .�-✓� ...�. =� ,� ,l � # zz----(r�-�'
...............- ------ -�._........I...--•---------•-• ---------
r Sfre�/r
as shown on the application for Disposal Works Construction Pe(ritfN��'"__� ___ Dated._ `f>f`
Board of Health
DATE....; � _ ..� -------------------
FORM 36508 HOBBS♦4 WARREN,INC.,PUBLISHERS